ASSI Monograph Safe Spine Surgery
ASSI Monograph Safe Spine Surgery
Avoiding Adverse Events and Improving Outcomes
Editors-in-Chief
Shankar Acharya MS FRCS (Ortho) MCh (Ortho)
Chairman Department of Spine Surgery Consultant Orthopedic and Spine Surgeon Sir Ganga Ram Hospital New Delhi, India
Amit Jhala MS DNB (Ortho)
Senior Consultant Spine Surgeon Chief and Director Department of Spine Surgery HCG Multispecialty Hospital Ahmedabad, Gujarat, India
Associate Editors
Amol Rege MS (Ortho) MCh (Ortho) D (Ortho) DNB (Ortho) MSc (Ortho) FRCS (Tr & Ortho)
Consultant Spine Surgeon Department of Spine Surgery Deenanath Mangeshkar Hospital and Research Centre Pune, Maharashtra, India
Pankaj Kandwal MS (Ortho)
Professor, Head and Program Chair Department of Orthopedics All India Institute of Medical Sciences Rishikesh, Uttarakhand, India
Foreword
Rajiv K Sethi
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ASSI Monograph Safe Spine Surgery
First Edition: 2022
9789354656927
Printed at
- Abhay Nene MS (Ortho)
- Consultant Spine Surgeon
- Department of Spine Surgery
- Lilavati Hospital and Research Centre
- Mumbai, Maharashtra, India
- Abhishek Srivastava MBBS MS (Ortho)
- Senior Consultant
- Department of Spine Surgery
- Max Super Specialty Hospital
- New Delhi, India
- Ajoy Prasad Shetty MS
- Senior Consultant
- Department of Spine Surgery
- Ganga Medical Centre and Hospitals Pvt. Ltd.
- Coimbatore, Tamil Nadu, India
- Akshay Gadiya MS (Ortho)
- Consultant Spine Surgeon
- Department of Spine Surgery
- Medicover Hospitals
- Aurangabad, Maharashtra, India
- Ambadas Kathare DNB
- Consultant Spine Surgeon
- Department of Spine Surgery
- Udai Omni Hospital
- Hyderabad, Telangana, India
- Amit Jhala MS DNB (Ortho)
- Senior Consultant Spine Surgeon
- Chief and Director
- Department of Spine Surgery
- HCG Multispecialty Hospital
- Ahmedabad, Gujarat, India
- Amol Rege
- MS (Ortho) MCh (Ortho) D (Ortho) DNB (Ortho)
- MSc (Ortho) FRCS (Tr & Ortho)
- Consultant Spine Surgeon
- Department of Spine Surgery
- Deenanath Mangeshkar Hospital and
- Research Centre
- Pune, Maharashtra, India
- Archit Goyal
- MBBS (MAMC) MS (Ortho, AIIMS) DNB (Ortho)
- Senior Resident
- Department of Orthopedics
- All India Institute of Medical Sciences
- New Delhi, India
- Arvind G Kulkarni MBBS MS (Ortho)
- Consultant Spine Surgeon
- Department of Spine Surgery
- Mumbai Spine Scoliosis and Disc
- Replacement Centre
- Bombay Hospital and Medical
- Research Centre
- Mumbai, Maharashtra, India
- Arvind Jayaswal MBBS MS (Ortho)
- Head and Director
- Department of Spine Surgery
- Max Super Specialty Hospital
- New Delhi, India
- Ashish Kukreja MS (Ortho)
- Spine Fellow
- Department of Spine Surgery
- Manipal Hospital
- Bengaluru, Karnataka, India
- Balamurugan Thirugnanam MS (Ortho)
- Spine Fellow
- Department of Spine Surgery
- Manipal Hospital
- Bengaluru, Karnataka, India
- Bhavuk Garg MS MRCS FACS FIMSA FICS
- Additional Professor
- Department of Orthopedics
- All India Institute of Medical Sciences
- New Delhi, India
- Brandon Weiss BS
- Second Year Medical Student
- Lake Erie College of Osteopathic Medicine
- Erie, PA, USA
- Chandhan Murugan DNB
- Senior Registrar
- Department of Spine Surgery
- Ganga Medical Centre and Hospitals Pvt. Ltd.
- Coimbatore, Tamil Nadu, India
- Denver Kraft MD
- Orthopedic Resident
- Department of Orthopedic Surgery
- MedStar Georgetown University Hospital
- Washington, DC, USA
- Dhanish Mehendirattta MS (Ortho) FASSI FAOS
- Spine Surgery Unit
- Department of Spine Surgery
- PD Hinduja National Hospital and Medical Research Centre
- Mumbai, Maharashtra, India
- Gautam Zaveri MS D (Ortho) DNB
- Director
- Department of Spine Surgery
- Jaslok Hospital and Research Centre
- Mumbai, Maharashtra, India
- HS Chhabra MBBS MS
- Chief of Spine Services and Medical Director
- Department of Spine Surgery
- Indian Spinal Injuries Centre
- New Delhi, India
- Jwalant S Mehta
- MS (Ortho) MCh (Ortho) D (Ortho) FRCS (Tr & Ortho)
- Consultant Pediatric and Adult Spine Surgeon
- Department of Spine Surgery
- Royal Orthopaedic Hospital
- Birmingham Children's Hospital
- Birmingham, England, UK
- Kamran Farooque
- MS (Ortho) MRCS (Glasgow, UK)
- Professor
- Department of Orthopedics
- JPNATC
- All India Institute of Medical Sciences
- New Delhi, India
- Krothapalli Srinivasa Babu PhD
- Senior Scientist
- Neurophysiology Laboratory
- Department of Neurological Sciences
- Christian Medical College
- Vellore, Tamil Nadu, India
- Mazda Turel MBBS MCh (Neurosurgery)
- Consultant Neurosurgeon
- Wockhardt Hospital
- Mumbai, Maharashtra, India
- Nischal Ghimire MBBS MS (Ortho)
- Post-Doctoral Fellow
- Department of Spine Surgery
- Christian Medical College
- Vellore, Tamil Nadu, India
- Pankaj Kandwal MS (Ortho)
- Professor, Head and Program Chair
- Department of Orthopedics
- All India Institute of Medical Sciences
- Rishikesh, Uttarakhand, India
- PK Karthik Yelamarthy MS DNB FNB
- Consultant Spine Surgeon
- Department of Spine Surgery
- Udai Omni Hospital
- Hyderabad, Telangana, India
- Prashant Kekre MS (Ortho)
- Consultant Spine Surgeon
- Department of Spine Surgery
- Sundaram Medical Foundation and Dr Rangarajan Memorial Hospital
- Vijaya Institute of Trauma and Orthopaedics
- Chennai, Tamil Nadu, India
- Pratik Patel
- FNB (Spine) DNB (Ortho) D (Ortho)
- Spine Surgery Unit
- Department of Spine Surgery
- PD Hinduja National Hospital and Medical Research Centre
- Mumbai, Maharashtra, India
- Praveen VNR Goparaju MBBS MS (Ortho)
- Clinical Spine Fellow
- ASSI (Association of Spine Surgeons of India)
- Department of Spine Surgery
- Bombay Hospital and Medical Research Centre
- Mumbai, Maharashtra, India
- Priya Narwal MBBS
- Resident
- Department of Neurosurgery
- All India Institute of Medical Sciences
- New Delhi, India
- Promod Kumar Kohli MS PhD (Surgery) LLB
- Freelance Medicolegal Consultant
- New Delhi, India
- Pulak Vatsya MS (Ortho)
- Senior Resident
- Department of Orthopedics
- All India Institute of Medical Sciences
- New Delhi, India
- Raghava D Mulukutla
- MS (Ortho) FRCS (Edin) MCh (Ortho) Liv.UK
- Director and Chief of Spine surgery
- Department of Spine Surgery
- Udai Omni and Apollo Health City
- Hyderabad, Telangana, India
- Rajiv K Sethi MD
- Clinical Professor and Spinal Surgeon
- Department of Spine Surgery
- University of Washington
- Virginia Mason Medical Center (Neuroscience Institute)
- Seattle, WA, USA
- Ram Chaddha MBBS MS (Ortho)
- Consultant Spine Surgeon
- Department of Orthopedic Surgery, Spine Surgery
- Lilavati Hospital and Research Centre
- Mumbai, Maharashtra, India
- Ravi Sharma MCh
- Fellow
- Department of Neurosurgery
- All India Institute of Medical Sciences
- New Delhi, India
- Richa Yadav MD (Radiology)
- Assistant Professor
- Department of Radiology
- All India Institute of Medical Sciences
- New Delhi, India
- Rishi Mugesh Kanna MBBS MS
- FNB Fellow in Spine Surgery from Ganga Hospitals
- Clinical Spinal Fellow from Queen's Medical Centre, Nottingham, UK
- Consultant Spine Surgeon
- Department of Spine Surgery
- Ganga Medical Centre and Hospitals Pvt. Ltd.
- Coimbatore, Tamil Nadu, India
- Rohit Amritanand MS (Ortho) MAMS FACS
- Professor
- Department of Spine Surgery
- Christian Medical College
- Vellore, Tamil Nadu, India
- S Rajasekaran PhD
- Professor and Chairman
- Department of Spine Surgery
- Ganga Medical Centre and Hospitals Pvt. Ltd.
- Coimbatore, Tamil Nadu, India
- Sachin A Borkar
- MBBS MCh (Neurosurgery) DNB (Neurosurgery) MNAMS
- Additional Professor
- Department of Neurosurgery
- All India Institute of Medical Sciences
- New Delhi, India
- Samarth Mittal MS (Ortho) DNB (Ortho)
- MCh Resident
- Department of Orthopedics
- All India Institute of Medical Sciences
- Rishikesh, Uttarakhand, India
- Samir Dalvie MS (Ortho) D (Ortho) FCPS DNB
- Head
- Department of Spine Surgery
- PD Hinduja National Hospital and
- Medical Research Centre
- Mumbai, Maharashtra, India
- Saumyajit Basu MS (Ortho) DNB (Ortho) FRCSEd
- Head
- Department of Spine Surgery
- Director of Spine Fellowships
- Kothari Medical Centre
- Kolkata, West Bengal, India
- Shankar Acharya MS FRCS (Ortho) MCh (Ortho)
- Chairman
- Department of Spine Surgery
- Consultant Orthopedic and Spine Surgeon
- Sir Ganga Ram Hospital
- New Delhi, India
- Sharvin Sheth MS (Ortho)
- Clinical Spine Fellow
- Department of Spine Surgery
- HCG Multispecialty Hospital
- Ahmedabad, Gujarat, India
- Shyam S Rendedla DNB
- Consultant Spine Surgeon
- Department of Spine Surgery
- Udai Omni Hospital
- Hyderabad, Telangana, India
- Suken A Shah MD FAOA FAAOS
- Vice Chair
- Department of Orthopedics
- Fellowship Director
- Division Chief, Spine and Scoliosis Center
- Professor, Orthopedic Surgery and Pediatrics
- Nemours Children's Hospital
- Wilmington, DE, USA
- Syed Ifthekar
- D (Ortho) DNB (Ortho) MCh (Spine)
- Department of Orthopedics
- All India Institute of Medical Sciences
- Rishikesh, Uttarakhand, India
- Thomas Kishen
- D (Ortho) DNB (Ortho) FRCS FSS (Australia)
- Consultant Spine and Scoliosis Surgeon
- Department of Spine Surgery
- Manipal Hospital
- Bengaluru, Karnataka, India
- Vijay Yanamadala MD MBA FAANS
- System Medical Director, Spine Quality and Surgical Optimization
- Hartford HealthCare
- Ayer Neuroscience Institute, Neurosurgery
- Associate Professor
- Department of Surgery (Neurosurgery)
- Quinnipiac University Frank H. Netter School of Medicine
- North Haven, CT, USA
- Vishal Kundnani
- MB MS (Ortho) FNUS FASSI FNAMS
- Consultant Spine Surgeon
- Department of Spine Surgery
- Lilavati Hospital and Research Centre
- Bombay Hospital and Medical Research Centre
- Mumbai, Maharashtra, India
- Vishnu Prasad Panigrahi
- MS (Ortho) FNB (Spine)
- Department of Spine Surgery
- Sir Ganga Ram Hospital
- New Delhi, India
Safety in Spine Surgery has made significant strides over the past decade and this positive movement has made the life changing and preserving the gift of spinal surgery available to children and adults in all corners of the globe. It has been my honor to participate vigorously in this movement as we have learned to work in teams, mitigate risk, use new technology and ultimately provide safer and higher quality spinal surgery to our patients. As a spinal deformity surgeon, this resonates with me daily as I care for the most complex adult spinal deformities from all regions of the USA.
The Indian scenario for providing high quality safe spine care, despite limited resources, has taught me a great amount over the past two decades. As a member of the diaspora embodying Indian pride and heritage, I salute the great ideals of our culture which aims to serve people and meet them at their greatest time of need. I have had the privilege and honor of operating with great Indian surgeons in Delhi, Mumbai and Chennai just to name a few. I have had the opportunity to chair two SRS worldwide courses in Ahmedabad and Hyderabad in conjunction with the ASSI annual meeting. Both events focused on safety and value bringing the world's greatest academic spinal surgeons to India from all over the globe.
We have learned that technology is our best friend when it comes to reducing harm to our patients. When this technology helps us plan or perform surgery at a more exact level, it can reduce unplanned return to the operating room. We have learned that high functioning teams outperform the smartest surgeon when the surgeon builds this fortress around himself/herself. Most importantly, we have seen that paying acute attention to the literature around safety in the care of frail adult patients will show tremendous progress in the coming years. Much of the attention in previous years has been focused on the intraoperative phase of care. This might be in pedicle screw design, cage design or in design of enabling technologies like robots and navigation. In the next decade, you will see an equivalent amount of industry, energy being paid to the preoperative phase of care. The concept of optimization of the spine surgical patient will be enhanced by virtual care and predictive analytics resulting in patient-specific prehabilitation and patient-specific surgical plans and implants. The planning of surgery will become more automated and errors will be eliminated by this process. The aviation industry has taught us a great deal about the culture of safety and the need to eliminate variability. This true north will continue to guide thought leaders in safety in spine surgery.
This book is an important effort by the Association of Spine Surgeons of India to educate surgeons and their associated colleagues on the current best practices around safety in spinal surgery. This is a sentinel effort to ensure that patients around India get the best care possible despite limited resources. The COVID-19 pandemic has laid bare the inequalities that many of our fellow humans face on a daily basis. As surgeons and healers, we will have to work even harder to provide access to our life changing procedures that maintain function and movement. Nobody is better suited to lead the way in this work than the spinal surgeons of India.
Jai Hind!
Rajiv K Sethi MD
Clinical Professor and Spinal Surgeon
Department of Spine Surgery
University of Washington
Virginia Mason Medical Center (Neuroscience Institute)
Seattle, WA, USA
Preface
Association of Spine Surgeons of India (ASSI) over the last few years has come up with monograms on various topics in Spine Surgery.
These have been well-received and has benefited both students in training and consultants in practice.
In the last decade, spine surgery in India and across the world has seen an exponential growth both in terms of volume, and in technological advances in techniques of spine surgery. Minimizing surgical errors and maximizing patient safety is of paramount importance in the present times.
This monogram entitled Safe Spine Surgery covers a wide spectrum of topics keeping in mind the importance of safety and accuracy in spine surgery.
As President ASSI, it is my privilege and honor to write this for the monogram. I extend my special thanks to Dr Amit Jhala and his Co-Editors Amol Rege and Pankaj Khandwal for bringing out this excellent monogram with contributions from authors across the world.
I am sure all members of the ASSI will find it useful.
Jai Hind!
Shankar Acharya
President ASSI
Introduction
In past two decades, spine surgery has an exponential growth because of with increased awareness, improvement in understanding, diagnostic technology and development of modern technology for spine surgery. More complex spine surgeries are also being performed which were thought impossible in past with overall improved outcomes of spine surgery. Although the outcomes of spine surgery have improved, spine surgery itself has higher and more disabling complication rates and adverse events during the surgery. These numbers are also affected by the large volumes of spine surgery being done at different centers. There is also a frequent gap in patient expectations and surgeons’ expectations, even after perfectly done procedure in the outcome of spine surgery. This has also increased the medicolegal law suits which are also highest in spine surgery. Hence, it is very important in these modern days to have a “Safe Spine Surgery” by avoiding the adverse events and hence improving the outcomes. The safety applies in spine surgery not only in improving the surgical skills by technology but also goes much more beyond improving the procedural challenges. It involves precision in all the steps of patient care from, decision making, preoperative evaluation, preoperative preparations, patient counseling and education with informed consent of the procedure, meticulous surgical technique with good postoperative care. From admission to discharge there can be numerous sources of errors like administrative errors, nursing and communication between the healthcare providers. The surgery is a team approach by multiple teams of different specialties leading to communication errors between the teams. The spine surgeon requires not only a good surgical skill, but also requires a true leadership quality to coordinate within his team and other departments to make the process of patient care absolutely safe.
This monograph is very important in modern days which deals with all the aspects of improving the safety in spine surgery from surgical checklists, safety protocols, risk stratification and patient counseling, multidisciplinary team approach, insight into modern surgical technology for precision spine surgery, improving the postoperative protocols, improving the nontechnical skills and lastly how to deal with legal aspects in case of complications.
Amit Jhala
Editor-in-Chief